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< SWRCB,January 2006 <br /> 9. l Bucket Testing ReporWlohlorm <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON #201383 (N-2515) DateofTesting: 02/11/2010 <br /> Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW, TRACY, CA, 95376 <br /> Facility Contact: MGR - HELEN Phone: (2 0 9) 836-3181 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): THUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DANIEL ROLLINS <br /> Credentials): ❑CSLB Contractor E ICC Service Tech. ❑SWRCB Tank Tester E Other(Spec) ICC <br /> License Number: 801161OUT <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: El Hydrostatic El Vacuum 0 Other <br /> Test Equipment Used:TEST EQUIPMENT Equipment Resolution:l IN WC <br /> Identify Spill Bucket(By Tank i SUP FILL <br /> 2 2 PLU FILL 3 3 REG FILL 4 <br /> Number,Stored Product, etc) <br /> F-1Direct Bury ❑Direct Bury F-1Direct Bury ❑Direct Bury <br /> Bucket Installation Type: <br /> ❑X Contained in Sumpx❑ Contained in SumpX❑Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11 11 11 <br /> Bucket Depth: 13 1/2 14 1/2 14 1/2 <br /> Wait time between applying 1 MIN 1 MIN 1 MIN <br /> vacuum/water and starting test: <br /> Test Start Time(TI ): 0925 0923 0920 <br /> Initial Reading(RI ): 30 30 30 <br /> Test End Time(TF ): 0926 0924 0921 <br /> Final Reading(RF ): 28 28 28 <br /> Test Duration: 1 MIN 1 MIN 1 MIN <br /> Change in Reading(R F-RI ): -2 -2 -2 <br /> Pass/Fail Threshold or -4 -4 -4 <br /> Criteria: <br /> Comments - (include information on repairs made prior to testing and recommended follow-up for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: 14 U((1 A-S Date: 02/11/2010 <br /> I State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br />